Robotic minor hepatectomy: Optimizing outcomes and cost of care

Abstract

Presenter: Camille Stewart MD | City of Hope Cancer Center Background: We have previously demonstrated that robotic-assisted hepatectomy has advantages for locations otherwise difficult for laparoscopy, while avoiding the morbidity of a laparotomy. We hypothesized that patients who underwent robotic-assisted minor liver resections would have superior peri-operative outcomes resulting in decreased overall peri-operative cost of care. Methods: We queried the electronic medical record for patients who underwent a liver resection from 1/1/16-8/14/19 (n=282). Concurrent major visceral resection, hepatic artery infusion pump placement (n=142), and laparoscopic approach (n=6) were excluded. Demographic, clinical, and peri-operative financial data were analyzed. Financial data included operating room, room and board, laboratory, and pharmacy charges normalized to Medicare reimbursements based on 2017 diagnosis related groups. Data were compared using Chi-square, Mann-Whitney, Kruskal-Wallis, logistic and linear multivariable analyses where appropriate. Results: There were 134 patients who underwent a liver resection: 80 open (60%), 54 robotic (40%). Of these patients, there were 41/80 (51%) open and 46/54 (85%) robotic minor hepatectomies (1-2 liver segments). Patients who underwent minor hepatectomies were similar in age, body mass index, comorbidities, and percent with prior abdominal surgery by operative approach (all p>0.05). Specimen size (257+/-152 vs 172+/-60 cc), surgical duration (277+/-27 vs 233+/-26 minutes), estimated blood loss (194+/-62 vs 187+/-71 mL), and margin status (93% vs 89% were also similar, yet complications (10/41, 24%, vs 3/46, 7% p=0.02) and length of stay (6.2+/-0.9 vs 2.3+/-0.7, p<0.001) were both significantly higher for patients who underwent open resection. These findings persisted in multivariable analysis. Patients who underwent open minor liver resection were 3.4 times more likely to stay longer (95% CI 2.1-4.8, p<0.001), and 7.8 times more likely to develop a complication (95% CI 1.1-57.5, p=0.02) compared to patients who had robotic surgery. Minor robotic liver resections had a median total cost $560 lower than open resections ($3239 (IQR 2322-4065) vs $3799 (IQR 3030-5195), p=0.03), due to lower cost for room and board, labs, radiology, pharmacy, and physical therapy (Figure, *statistical significance). Operating room costs were higher for robotic operations, but this did not achieve statistical significance ($2107 (IQR 1669-3076) vs $1951 (IQR 1458-2425), p=0.08). In multivariable analysis, the primary factor associated with increased total cost was development of complications (p=0.001). Only 3/46 (7%) of robotic minor hepatectomies required conversion to an open operation; these patients had similar surgical duration, estimated blood loss, post-operative complications, length of stay, and total cost when compared to those who started with an open approach. Conclusion: Patients who underwent robotic minor liver resections had fewer complications, shorter hospitalizations, and lower total cost for care when compared to those who underwent open operations. There was no patient or financial penalty for starting robotically and converting to an open operation. This suggests that when feasible and appropriate, a robotic approach should be the goal for minor liver resections.